(Please Delete All Directions in Parentheses in the Final Draft Or the Document Will Be

Research Title Researcher’s Name

San Francisco State University Parental Permission for a Minor to Participate in Research Research Title

A. PURPOSE AND BACKGROUND My name is ______. I am a (graduate student/ faculty member) at San Francisco State University (state your department here) and I am conducting research about ______. I am inviting your child to take part in the research because he/she ______. (State the purpose of the research; the purpose must be the same as stated in the protocol. State why the prospective subject is being invited to participate in this study, e.g. “he/she is in my algebra class,” “he/she is in the after school program I am studying,” “he/she is a student in ______high school,” or other inclusion criteria)

B. PROCEDURES If you agree to let your child participate in this research, the following will occur:  Your child will be asked to (play math games and take a test)  This will take place in their regular classroom as part of my scheduled curriculum. (OR///)  Your child will participate in a group discussion in social studies class about their attitudes about extracurricular activities. The discussions will be audio recorded. OR///  Your child will be invited to participate in an after school tutoring project. The tutoring sessions will take place between 3:45 and 4:45 PM on five Tuesdays and Thursdays during the spring semester. (This section must mirror the procedures stated in the protocol. State where the research will take place, how long it will take, at what time of day it will occur, and who will be present in the room with the child. State the time each procedure will take, and also state the total time it will take. Use the pronoun “you” and “your child” when referring to the parents/guardians and prospective minor participant.)

C. RISKS There is a risk of loss of privacy, which the researcher will reduce by not using any real names or other identifiers in the written report. The researcher will also keep all data in a locked file cabinet in a secure location. Only the researcher will have access to the data. At the end of the study, data will be ______. There may be some discomfort at being asked some of the questions. You may answer only those questions you want to, or you may stop the entire process at any time, without penalty to yourself. State the risks involved, and how the researcher will reduce them. Risks must mirror those stated in the protocol. State the final disposition of the data. If you will want to follow up in any way, get permission in this consent Add the “discomfort” paragraph only if you are asking sensitive questions. If the children are very young, add that “if the child indicates in any way that he/she does not 1 of 3 Research Title Researcher’s Name want to participate, by crying or other behavior, we will stop immediately.” Also, if the questions are very sensitive and may cause anxiety or other negative emotions, researcher should include a brief list of counseling contacts they may consult. D. CONFIDENTIALITY In this section, state how you will protect the confidentiality of the data collected. Where will you store it, that it will be on an encrypted document on a password-protected computer for electronic data, or in a locked office in a specific location for paper data. For students, data or any identifiable information must be kept in the faculty member’s office. Also, how long will the data be kept, what will happen to it when the project is over (will it be destroyed, kept for future research—if so the research must be consistent with the original purpose)? Please note that you can keep all research data for as long as you want, but the CSU policy for storing data states that all data must be kept for a minimum of three years. (If recording interviews and transcribing them for the content): Audio or video recordings will be destroyed at the end of the study.

(If keeping original recordings or digital data for future research, data may be used in the future only for research purposes consistent with the original purpose of the research stated in this consent. If the data is de-identified, i.e all identifiers have been removed including coding, the data will not need IRB review for future research use.

Sample: The research data will be kept in a secure location (or encrypted on a password- protected computer), and only the researcher will have access to the data. At the conclusion of the study, all identifying information will be removed and the data will be kept in a locked cabinet or office.

E. DIRECT BENEFITS There are no direct benefits for your child’s participation in this project. (Benefits section must mirror the protocol statement.)

F. COSTS There will be no costs for your child’s participation in this project. OR//Costs will include transportation to the research site, parking and lunch. (This section must mirror the costs stated in the protocol.) G. COMPENSATION There will be no compensation for participation in this project. OR// Participants will receive a gift certificate for $10 for Old Navy Stores. (This section must state the same compensation offered, if any, as in the protocol. If no compensation is offered, say so here. Please indicate if/how participants will be compensated if they do not complete the research.)

H. ALTERNATIVES The alternative is not to participate.

I. QUESTIONS

2 of 3 Research Title Researcher’s Name

You have spoken with (researcher’s name) about this study and have had your questions answered. If you have any further questions about the study, you may contact the researcher by email at (researcher’s email address), or you may contact Professor (supervising instructor’s name – use “Professor” or “…, Ph.D.” instead of “Dr.”), by calling (415: 338-department phone number) or (supervisor’s email address).

Questions about your child’s rights as a study participant, or comments or complaints about the study also may be addressed to Human and Animal Protections at San Francisco State University, at 415-338-1093 or [email protected].

J. CONSENT You have been given a copy of this consent form to keep. PARTICIPATION IN THIS RESEARCH IS VOLUNTARY. You are free to decline to have your child participate in this research. You may withdraw your child’s participation at any point without penalty. Your decision whether or not to participate in this research will have no influence on your or your child’s present or future status at San Francisco State University (or at

Child’s Name ______

Signature ______Date ______Parent/Guardian

Signature ______Date ______Researcher

(Once the italicized instructions have been removed, the consent document should be kept to 2 pages. You may delete double spaces between sections if necessary.)

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